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Supporting Guidance Standard 4.2

Health and Care Standards

Supporting Guidance

Standard 4.2: Patient Information


What is the Standard about?

Patients, service users and carers are provided with information to inform decisions including any changes to lifestyle that would improve, or prevent further deterioration of their condition.

Health professionals must also remember their duty to keep themselves informed of legal developments which may have a bearing on their practice. Legal advice should always be sought if there is any doubt about the legal validity of a proposed intervention. 

This standard reflects the right of patients to determine what happens to their own bodies, and is a fundamental part of good practice to obtain informed consent.

All decisions must be made in accordance with the Mental Capacity Act 2005. 

When treating children, health professionals should take particular care to ensure that they are familiar with the relevant law and should consider carefully whether the child is competent to give his or her consent to the treatment.

When treating people with learning disabilities, staff should make use of any information about the way that the person communicates such as a health passport or communication profile in their care notes, this will usually be with the person when they attend. The person’s record may also contain information on reasonable adjustments. Many people with learning disabilities access services accompanied by their families and care workers, speaking to the people who know the person best is an important way of learning how that person communicates.   


All staff must understand their responsibilities in respect of confidentiality and the serious consequences of any breaches.


Who is it for?

All healthcare staff and services in all settings

In relation to the standard criteria (in bold) the following key questions need to be considered:

People’s rights and individual circumstances are respected so they have a voice and control, empowering them to make decisions that affect their lives.

  • How do you ensure that patients, service users and carers are provided with timely information on their condition, care and treatment, medication and support arrangements, and can participate in decisions about their care?
  • How do you ensure that the information is given in a format that a patient, service user and carer with sensory loss can understand?

Welsh speakers are empowered to express their needs and they are able to fully participate in their care as equal partners.  Where needed people are provided with access to a translator or a member of staff with appropriate language skills.

  • Are service users asked for their personal preferences and opinions regarding the use of the Welsh language?
  • How do you ensure that people receive information about their care in Welsh?
  • Do you make an active offer (providing a service in Welsh without someone having to ask for it) when providing information to Welsh speakers?

Health, personal and social care needs are assessed and set out in regularly reviewed plans of care.

  • How do you ensure that a holistic assessment of need for those receiving secondary mental health services consider the 8 areas of life as part of care and treatment planning?
  • How do you ensure the patient has a care plan in place (either written or verbally agreed in their notes) which assesses their health, personal and social care needs?
  • How do you ensure care plans are regularly reviewed?

Assistance or specialist aids are provided to those with speaking, sight or hearing difficulties, special needs such as memory problems or learning disabilities, enabling them to receive and respond to information.

  • How do you record and flag the communication needs of patients with sensory loss on their medical record, so they do not have to repeatedly ask for assistance or specialist aids?
  • Do you make sure that the information that people with learning disabilities bring with them about their needs is incorporated into their plan of care?
  • Do you ask carers of people with learning disabilities about reasonable adjustments and act upon their advice?

People are consulted about any treatment and care they are to receive and opportunities provided to discuss and agree options.

  • How do you ensure that people receive information in a format that is accessible to them, so that they can participate in discussions about their care?
    • For people with sensory loss this may include:
      • asking what format they require written communication
      • ensuring they can access instructions for taking medication
      • the need to lip read,
      • access to assistive equipment,
      • the need to maintain hearing aids or
      • access to British Sign Language interpreters
  • How are patients given the opportunity to discuss and agree their options?
  • How can patients, service users and carers access information to inform their decisions? This may include outcome data, waiting lists, morbidity and mortality rates, HCAI rates, etc.
  • How do you know that the information is useful for patients?
  • Are clinicians provided with the appropriate tools to support shared decision making?

People’s personal records are kept safe regularly updated and available to them.

  • What arrangements do you have in place to provide someone’s personal record in a format that is accessible to them, such as braille, large print or audio?
  • How do you know that all staff understand their duty of confidentiality?

Time is taken to listen and actively respond to any questions and concerns that the individual or their relatives may have, treating their information confidentially.

  • How do you ensure that any printed information is available in a format accessible for patients with sight loss, so that they can access this information privately?

Valid consent is obtained in line with best practice guidance; and assessing and caring for people in line with the Mental Capacity Act 2005, and when appropriate the Deprivation of Liberty Safeguards 2009.

  • How do you know that all staff understand the implications of the Mental Capacity Act and their responsibilities? 
  • How do you ensure staff are fully aware of and comply with patient consent legislation and best practice?
  • How is compliance with patient consent legislation and best practice monitored?
  • How do you develop and implement methods and practises for providing patients with information about giving consent?
  • What have you learned from monitoring compliance with patient consent guidance and what changes have been made?
  • Do you identify complaints under the Mental Capacity Act?

Timely and accessible information is provided on people’s conditions and care, medication, treatment and support arrangements.

  • How do you ensure that patients, service users and carers are provided with timely information on:
    • Condition
    • Care and treatment choices
    • Medication options- including risks and potential benefits
    • Support arrangements?
  • How do you ensure that the information is given in a format that the patient, service user and carer can understand including those with sensory loss?
  • How are you extending the possibility of patients managing their own care with appropriate information and support.


Legislation and Guidance




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